- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.28 / $936.00 / $2,010.00
| Facility | | $169.28 | $936.00 | $2,010.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.28 / $268.70 / $295.57
| Professional | | $169.28 | $268.70 | $295.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.75 / $593.75 / $593.75
| Facility | | $593.75 | $593.75 | $593.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.00 / $375.00 / $375.00
| Professional | | $375.00 | $375.00 | $375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $42.50 / $50.00
| Professional | | $21.25 | $42.50 | $50.00 |